673 - A Pilot Study Examining Parent Engagement and Novel High Resolution Manometry (HRM) Methods on Aerodigestive and Economic Outcomes in Infants

Publication Number: 4658.673

Sudarshan R. Jadcherla, Nationwide Children's Hospital, Columbus, OH, United States; Roseanna Helmick, Nationwide Children's Hospital, Columbus, OH, United States; Erika K. Osborn, Nationwide Children's Hospital, Canal Winchester, OH, United States; Toni Plumb, Nationwide Children's Hospital, Grove City, OH, United States; Enas Alshaikh, Nationwide Children's Hospital, columbus, OH, United States

Background: The prevalence of chronic tube feeding with aerodigestive and pulmonary disorders is high in tertiary care neonatal ICUs (NICUs). While safe feeding is necessary for discharge, parent engagement with oral feeding sessions can be difficult which can prolong discharge decisions and length of hospital stay (LOHS). Parental frustration ensues when gastrostomy (G-Tube) is suggested as an alternative discharge feeding strategy.

Objective: Our aim was to engage parents during our weekly diagnostic high-resolution manometry (HRM) protocol by educating parents on pharyngoesophageal function and providing biofeedback based on direct evidence. We hypothesized that this weekly HRM and parent participation protocol would improve feeding outcomes and decrease LOHS.

Design/Methods: Nasogastric tube fed neonates who missed their oral feeding milestones and were under consideration for a G-Tube were evaluated using weekly HRM until discharge or up to 4 weeks. We examined and explained resting state aerodigestive reflexes, adaptive reflexes with pharyngoesophageal provocation, and oral feeding mechanisms at the weekly HRMs to evaluate the change over the study period (Figure 1). Parents were provided with objective biofeedback and their questions on their infant's feeding abilities were addressed. The infants' vitals and respiratory status were monitored continuously. Appropriate statistical methods were used to examine the hypothesis.

Results: Demographics and outcomes of the infants enrolled and evaluated with the above described protocol are shown in Table 1; 14/18 (78%) infants were oral-fed at discharge with 9/18 (50%) fully oral-fed and 5/18 (28%) required G-Tube for supplemental nutrition. The proportion of parent involvement (%) was higher in infants who were discharged full oral vs with a G-Tube (32 vs 12, p=0.03). The effect of parent and specially trained staff involvement on outcomes is shown in Figure 2. At 1 year follow-up: a) 17/18 (94%) infants were oral-fed (67% full, 27% partial) and 6% via G-Tube only. b) 15/18 (83%) infants had no respiratory support and 3 (17%) were using a nasal cannula.

Conclusion(s): Our HRM protocols offer biofeedback for parent-infant dyad, and educational opportunities for feeding therapists, nurses, providers, and parents to pursue physiological evidence-based management. Clinical trials are needed to examine ways of increasing parent engagement to improve pre- and post-discharge feeding habilitation and rehabilitation. The goal is to minimize chronic disease in high-risk NICU infants by improving feeding independence, neurodevelopmental- and socioeconomic outcomes.

Table 1. Clinical and Outcome Characteristics
Data as n (%) or mean ± SD. *Two G-Tube recipients progressed to full oral in 2 months.

Figure 1. Visual representation of the change in pharyngoesophageal HRM characteristics with our protocol.
AU- Arbitrary units, LES-Lower esophageal sphincter, Resp-Respiratory, UES-Upper esophageal sphincter. Note the improvement of manometry patterns over time with basal spontaneous swallowing, mid-esophageal (ME) stimulation with infusions, and oral feeding challenge test (OFCT).

Figure 2. Effect of parent engagement by our specialty program on outcomes.
Parent involvement (%) was measured by the percent of oral feeds given by the parents over the total number of feeds during the study period. Trained staff involvement (%) was measured by the percent of oral feeds given by our specialty nurses over the total number of feeds during the study period. The red circles denote the infants who were orally feeding but needed nasogastric tube feeds upon discharge for supplemental nutrition. A) The LOHS decreased as the parent involvement increased. B) The LOHS decreased as the parent and trained staff involvement increased. C) The proportion of the feed taken orally increased as the parent involvement increased. D) The Kaplan-Meier curve shows that nine infants remained on tube feeding ≥20 days after inception. The median probability of remaining on tube feeding occurs at 28 days after inception which coincides with maximum study duration (4 weeks). The censors indicate the infants that did not reach full oral feeds before the end of the study period but feeding outcomes were still followed.